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Page 2 of 10 Sticchi et al. Vessel Plus 2018;2:23 I http://dx.doi.org/10.20517/2574-1209.2018.47

access is recognized as the least invasive and consequently it makes best use of the sheaths currently avail-
able. Other access options include transapical access, transaxillary, transcarotid access or a direct aortic
approach. These have specific advantages and disadvantages and are used in those cases where there is no
[4]
fitting anatomy to ensure safer trans-femoral access (TF) . In order to achieve procedural success and avoid
foreseeable complications, careful planning of the TAVI access site and route is essential. This is achieved
through the pre-procedural study of the vessels involved in terms of both caliber and severity of tortuos-
ity and calcification. Therefore, an appropriate high-quality computed tomography (CT) scan with contrast
[5]
injection is required while arteriography and intravascular ultrasound (IVUS) furnish additional data .
In this review we describe the different vascular access characteristics as well as the most relevant vascular
complications.

TF ACCESS
[6,7]
Current experts’ consensus strongly supports the use of femoral artery as preferred access site for TAVI .
In consideration of the feasibility of using both a surgical and percutaneous approach through the femoral
artery, besides the chosen option, the operator’s attention must be paid to preserve the vessel from possible
[6,7]
damage in its use . Although, reducing the size of the sheath with the new generation of devices, a small
proportion of patients still exhibits unfavourable iliofemoral arteries that compel them to adopt different
[4]
approaches . The techniques of choice for vessel closure, including percutaneous puncture and prelimi-
nary suture, are performed under loco-regional anaesthesia and require open surgical access up to 20% of
[6,7]
cases . These conversions from percutaneous insertions into open or hybrid repairs apply vascular surgery
[6,7]
closure techniques or percutaneous closure devices that reproduce them .
TF access using a surgical cutdown
Since the sheaths of the first devices show large sizes of about 22-French (Fr) to 24-Fr, early TAVI experi-
[7]
ences required surgical access to isolate the artery and access it . Surgical approach with tissue cutting and
artery exposure is the first step in such a planned procedure and it allows to examine the vessel by checking
the quality of the wall identifying optimal puncture site and at the same time potential vascular injuries can
easily be controlled and repaired during one procedure. Alternatively, the procedure is performed by percu-
[8,9]
taneous puncture and the artery is treated surgically only to provide for closure of the vessel . Reported
predictors of vascular complications in TF TAVI include moderate to severe iliofemoral calcified vessels as
well as low femoral artery sheath to artery ratio and in this situation performing a surgical approach is pref-
[8,9]
erable . Moreover, there are cases that deserve particular indications to come along surgically as an exces-
sive depth of the vessel, as in individuals suffering from obesity, the presence of grafts or femoral stents or
[8,9]
an anatomy that requires a higher puncture than the standard as in the case of high femoral bifurcation .
However, the surgical approach is associated with wound complications such as lymphoceles, paraesthesia,
and potential wound infection which may delay early patient mobilization, a crucial component of the recov-
ery process for elderly patients who are prime candidates for this procedure [10,11] . Even if the use of surgery
becomes unsustainable due to the the incompetence to accomplish a safe femoral access, it is recommended
to consider other possible different accesses in order to avoid predictable complications, arising from the
[8,9]
hostility of the route, that inevitably impact on morbidity and mortality of the patient .

Percutaneous TF Access
The incidence of major vascular complications have decreased significantly from 15.3% in the TF cohort of
the Placement of AoRTic TraNscathetER Valve Trial (PARTNER) trial utilizing 22 Fr and 24 Fr introducer
sheaths to 4.2% in the Transcatheter Valve Therapy (TVT) Registry. Among them, life-threatening scenario
are the thoracic aortic dissection, access-related vascular injury leading to death or significant blood trans-
fusions, distal embolization from a vascular source requiring surgery or resulting in irreversible end-organ
[12]
damage . Thanks to reduced sheath size as well as the improvements in delivery systems and patient selec-
tion based on vascular assessment through the CT angiography, TAVI procedure can be done completely